SELF-ASSESSMENT of COMPANION ANIMAL MEDICAL RECORDS
Case Type: ______________________________________
File Identifier: ________________________
Date of Specific Visit(s) under Review: _______________________________________________________
Name of Individual/Team Completing this Self-Assessment: _____________________________________
Date of Self-Assessment: ___________________________________________________________________
COMPONENT
Present?
Y / N
or
NA
Complete? Easy to find?
Y / N
Y/N
or
or
NA
NA
Comments?
Could be
Improved

Identification
1. Patient
a) Name/Species/Date of Birth/Sex/Breed/Colour is on file
b) patient name or ID # is on every page of the record
2. Client(s)
a) Name/Address/Phone/Alternate methods of contact for
each b)Name or ID# is clearly marked on each page of the file
3. Emergency Contact when animal is confined with member.
Name, address, and phone numbers of an emergency contact
authorized to act as an agent for the owner is on file.



Dates
1. Each entry in the medical record is dated, regardless of
whether or not the animal is literally seen

History
1. Description of presenting complaint is captured

2. Description of overall health is noted

3. Cumulative Patient Profile or Master Problem List is
included and updated
4. Vaccination History
(a) vaccination type (killed, live, lot, serial#, manufacturer,
diseases)
(b) Site and Route of vaccination (in record or via protocol
in the clinic)



Assessment
1. Physical Exam Findings
(a) Written out, or via check-list template, or contained
in protocol on site (more than NSF or NAF is recorded)
(b) Animal’s weight is recorded at each visit


Self-Assessment of Records, p.1
COMPONENT
Present?
Y / N
or
NA
Complete?
Y / N
or NA
Easy to
find?
Y/N
or NA
Comments?
Could be
Improved

(c) Differential diagnoses are listed

(d) Provisional/final diagnosis included

(e) Diagnostics:
Record of diagnostic plans to clarify assessment; results
retained in record; results interpreted and interpretation
noted

Treatment Plans
1. Plan of action, including follow-up plans, recorded
2. Drug treatments:
Name of drug/strength/dose/quantity/directions for
use; repeats/warnings are all included
3. Detailed surgical notes or protocols are present



4. Anesthetic / analgesic notes or monitoring forms are present

5. In-hospital monitoring notes are present

6. Fluid therapy: type/rate/route/amount received/medications
added are detailed

Client Communications and Professional Advice
1. There are signed consent forms for procedures (not just
surgical consent forms).
2. Cost estimates are used for all diagnostic tests or procedures
(not just surgical procedures).
3. There is an indication that discussion took place and
informed consent was obtained
4. Declined diagnostic investigations and treatment plans are
recorded
5. Ongoing communications documented for hospitalized
patients
6. Homecare or Discharge Instructions were provided and
documented in the record (copy in the record or reference to
a template).
7. Client Education information/forms were provided and are
Documented (either by copy or reference to a template).
8. Personal and telephone / FAX / email communication with
/messages for clients are included and documented by date.
9. Referral letters/ reports are included in the record, and
follow-up communication with owner is documented









Reports
A copy of all reports prepared with regard to the patient
(vaccination certificates, referral letters, etc)

Self-Assessment of Records, p.2
COMPONENT
Present?
Y / N
or
NA
Complete?
Y / N
or NA
Comments?
Could be
Easy to
find?
Y/N
or NA
Improved

Fees and Charges
Fees and charges are noted in file, with those for drugs listed
separately from those for advice or other services.

Radiographs
Radiographs are permanently identified with: name of
veterinarian or facility; patient ID; date; indication of L or R
side of the animal; indication of time for sequential studies

Logs
Appropriate logs/registers are maintained for:
anesthetic/surgery/radiology/controlled
drugs/ketamine/targeted drugs

Comments?
RECORDS MANAGEMENT
Y
N
N/A
Could be improved
Medical records are legible.









Records are kept in a systematic manner.
Changes in records are clearly indicated as changes.
Entries in the record are initialed.
Records are retained for 5 years after the date of the last entry.
A Records Security protocol is in place and staff is trained.
A policy on Privacy/Personal Information Protection is visible
to clients and understood by staff.
A procedure is in place for the transfer of medical information.
ASSESSMENT OUTCOME
As a result of this exercise, I / we have discovered or decided the following:
Areas for improvement in record keeping
Plans to address these areas
1.
1.
2.
2.
3.
3.
4.
4.
5.
5.
Self-Assessment of Records, p.3